21 May 2013

In the windows of the Subway cafeteria on the Auckland waterfront are the words “Whatever you need...whatever you crave...energy hit? ...get your fix here 24 hours”. On the back of a bus I saw an ad for a giant Carl’s Jr hamburger “Eat like you mean it” – the message is serious eating, absolute self indulgence, and no need for self-control or concern for the consequences.

Pity about the English language, but Oh – the excitement of the market place! It is, of course, about competition, making profits, inducing people to come back for more products that they do not need, but satisfaction is assured.

In recent decades, Western governments have embraced market fundamentalism to include the health service, in the name of efficiency and controlling costs. Now there is the possibility of new fees for patients, stripping elective surgery out of public hospitals to compete for State funding, and reducing costs by allowing nurses and pharmacists to take on some tasks performed by doctors. The consequences for patients are likely to be dire – but all consistent with the market ideology.

Clearly, managers are necessary. In National Women’s Hospital, on the basis that management is the same anywhere, we have had people from a brewery, garden centre, post office, an engineer and a physiologist – all nice people, but now there is a fifth layer of management between me and my employer, and it has prompted me to reconsider the organisation of public health services. We do not need any more control of the medical profession. No more guidelines with new paradigms; targets that simply cause problems for other parts of the service. All of these can mean that ethical values, co-operation and consultation are subsumed and the social determinants of health – inequality, housing and education, as well as the burden of obesity – are overlooked.

Measuring things

In the market, services are assessed by collecting data. ‘Measuring things’ is what is required by management. This has been used to create public league tables of hospitals, some of which led to the inquiry by Robert Francis QC into the Mid-Staffordshire Trust in the UK’s National Health Service. There seemed to be unreasonable numbers of adverse outcomes and a tolerance of poor practice within that organisation. Many failures were identified within the systems in place. The Francis Report describes overcrowding, insufficient numbers of trained staff, the rush to meet the four-hour target in the emergency department, consultants not involved in management, and failure by the Trust to supervise standards.

Newspapers claimed that 1200 patients died unnecessarily, but it is not clear how that number was reached; there were too many variables, bias and unknown factors in the data, which depended on unreliable coding and applied only to people in hospital. After the Inquiry into cardiac surgery in Bristol in the early 1990s, several companies were established to measure mortality, some of them for commercial gain. In the view of Paul Taylor, a reader in Informatics at University College London, the methods used are flawed, prone to error and not consistent between hospitals or companies.

One method is based on hospital episode statistics, which means that NHS authorities are supposed to know whether or not a patient died in hospital. The coding is based on the ‘first episode of care’ which could, of course, differ from the final diagnosis. Last year’s statistics include about 785,000 of these episodes coded under obstetrics – and of that number nearly 17,000 were men! Paul Taylor made the point that the system was not designed to measure the quality of care, only the quantity; also that 98% of inpatients survived their visit to hospital and that very few deaths were avoidable.

The British Government’s response to the Francis inquiry was released in March this year entitled Patients first and foremost. It proposed a duty of candour that they say will enable the NHS to become “more open, transparent and accountable, one which prioritises the patient care over corporate interest”. I say ‘Hallelujah’ but will not be expecting that to happen soon.

Could the problems of Mid Staffordshire happen here? Paul Ockelford posed that question in a recent Medspeak editorial: my answer is “Yes, to some extent they are”.

In the near future, more clinical indicators and outcome data will be available to assist Trusts detect problems, and scorecards to help the new chief inspectors. In general practice, there will be clinical commissioning groups who will bid against major companies for hospital services, which, writes one journalist in the Guardian Weekly, means British citizens can expect a boom in private profit with public mistrust and bankrupt hospitals.

Meanwhile, general practitioners become rationers and commissioners who can withhold part payment for an operation if a patient has not been treated to the “highest possible standard”. The power is still held centrally and the blame devolved to the workplace. There does not appear to be any thought in the UK that the current ideology of the marketplace may not be working well.

‘Unshackling’ the hospitals

Back home, in 1988, the findings of the task force chaired by Alan Gibbs were released under the heading Unshackling the Hospitals. The task force reviewed New Zealand hospitals, international developments in health economics and the management of health systems. It identified factors undermining public hospitals, mainly the absence of relevant information to guide decisions, poor management, underlying structural problems, obstacles to access to waiting lists for clinics and operations, and a shortage of long-stay beds. Morale was low in the hospital system and initiatives for change were discouraged.

The report gathered dust under the fourth Labour Government despite some good ideas. Since then there have been several changes, re-disorganisations of the public service in a truly unfortunate experiment to fit health care into the market place and the neo-liberalism of Ronald Reagan and Margaret Thatcher.

One problem is the expectation of a perfect outcome from every encounter, with journalists hovering to snatch a headline of bad news with scant opportunity for leadership to create a realistic understanding for New Zealanders about the effects of sickness and accidents.

Most headlines in the media are about failures of the health service, and clinical care is discussed, almost routinely, without all the relevant facts. Incidentally, some of the UK health trusts responded to bad publicity on league tables by re-arranging the coding.

In 1820 Georg Hegel published The Philosophy of the Right. In it he states that entrepreneurs are a major force in the expansion of the imagined rights of consumers...the market does not just satisfy wants, it creates them”.

As I was gazing out the window of my consulting rooms recently, a young man on a skateboard swept down the street – a busy, narrow one with cars parked on each side – earphones on his head and drinking a cup of coffee, apparently oblivious to any risk he was taking. But surely, if he gave it a thought, confidently expectant that the public health system would look after him and ACC would reimburse him for any damage, and he would not have to take any responsibility himself. These days his expectations would be considered reasonable; the vanity of entitlement.

We do have an amazing health service but there does seem to be a public assumption that diagnoses can be made immediately with perfect care whilst having no understanding of complexity and co-morbidities. Many people do just what they like, satisfy their cravings, take what I would call unreasonable risks and, if there is a bad outcome, there is someone to blame and an expectation that something would be done to make sure that it does not happen again.

There will always be some bad outcomes. Ethically our response to the inevitable bad outcomes is to be open and honest, to show compassion – it takes only a few minutes to say “Sorry, what can we do to support you” and give an explanation. The words “open disclosure” are used but I prefer to think it is just a humane thing to do.

Gavin Mooney, in his last book The Health of Nations, writes that there has been an erosion of values of care and common trust, mutual responsibility, respect for the vulnerable, justice and fairness. The question “Is it too late to turn back the clock on managerialism and neo-liberalism?” is posed in the editorial of the Internal Medicine Journal of the Royal Australasian College of Physicians this year in reference to the regimes of power of highly paid professional managers who have largely replaced older style academic, professional and cultural leaders.

Cost versus value

The collection of data has been useful in some respects. We now know the cost of most things, if not the value of them, and the three current pillars of clinical governance – patient safety, clinical effectiveness and patient experience – are reasonable. By the time doctors finish their training, they should know what safe practice of good quality is.

The coroner who reported on the recent death of a young man who died of meningococcal disease said “One of the realities of working and treating patients in the health care system is that there would be errors and deaths, despite the best efforts”. Most importantly, it is essential to the theory of quality improvement, that health professionals who err are encouraged to disclose their errors and oversights without fear of recrimination, so that lessons can be learned and the potential for repetition is minimised. It is unfair if judgements about health services are based on unreliable statistics.

I do hope that it is not too late to pause and reflect on the reliance of market mechanisms to address all the needs of a society; I believe that they are not suitable for a benevolent health system and they have exacerbated the inequalities in access to care.

The NZMA sets a fine example of involvement. It is heartening to read the affirmation that the Association will continue to advocate on the behalf of patients, to promote a culture of care and compassion and for involvement in clinical leadership; co-operation instead of competition, and more emphasis on the promotion of good health.

There will always be a need for the Association to provide expert advice, wise counsel and realistic expectations from clinical experience.

Finally there is wisdom in the words of Leonard Cohen; “Let the bells ring, the bells that can ring, forget the perfect offering, there are cracks, cracks in everything; to let the light in”.

By the way, the young man on his skateboard did reach the end of the street safely!